- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,513.56 / $1,737.80 / $2,454.71
| Facility | | $1,513.56 | $1,737.80 | $2,454.71 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,122.02 / $1,348.96 / $1,621.81
| Professional | | $1,122.02 | $1,348.96 | $1,621.81 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $870.96 / $1,819.70 / $2,238.72
| Professional | | $870.96 | $1,819.70 | $2,238.72 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $371.54 / $1,071.52 / $2,570.40
| Facility | | $371.54 | $1,071.52 | $2,570.40 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,047.13 / $1,230.27 / $2,238.72
| Professional | | $1,047.13 | $1,230.27 | $2,238.72 |